MEDizzy - A 62-year-old female is brought to the ED by EMS for

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Medicine test

A 62-year-old female is brought to the ED by EMS for confusion, headache, and vomiting over the past 12 hours. Vital signs are as follows: Temperature = 96.9°F, HR = 100, RR = 22, BP = 220/150. She is disoriented and uncooperative. Examination is otherwise unremarkable. What is the most likely diagnosis, and what is the most appropriate management?

ExplanationHypertensive emergency; rapid lowering of blood pressure with IV agents. Hypertensive urgency is defined as a systolic blood pressure >180 mm Hg and/or a diastolic blood pressure >120 mm Hg with no end-organ damage. Hypertensive emergency is the same definition with the addition of end-organ damage. Many organs are acutely affected by high blood pressure, including the brain (stroke), eyes (papilledema), heart (aortic dissection), lungs (pulmonary edema), and kidneys (renal failure). Within the umbrella term of hypertensive emergency, there are additional terms for specific end-organ involvement: malignant hypertension refers to hypertensive emergency in the presence of papilledema (other ophthalmologic findings include retinal exudates and hemorrhage), and malignant nephrosclerosis refers to renal damage. This patient has a hypertensive emergency with end-organ involvement including the brain (headache) and the eyes (papilledema). (A, B, C, E) The management of hypertensive urgencies and emergencies is slightly different. In hypertensive urgency, the goal is to gradually lower the blood pressure to achieve a normal value within a couple of days. Oral antihypertensive agents are given while monitoring the reduction in blood pressure over hours. Some options for oral medications include labetalol, captopril, clonidine, furosemide, and hydralazine. In hypertensive emergency, there is ongoing end-organ damage and therefore blood pressure needs to be lowered quickly. The goal in this setting is to immediately lower blood pressure using IV agents, targeting a decrease in mean arterial pressure by 25% within minutes to hours. Some options for IV medications include nitroprusside, nitroglycerin, calcium channel blockers (e.g., nicardipine), labetalol, hydralazine, fenoldopam, and phentolamine. Because adaptive mechanisms occur with chronically elevated blood pressure, rapid lowering of blood pressure is not always tolerated and can cause cerebral hypoperfusion. If this happens, the blood pressure must be lowered more gradually